Republicans in Congress have been saying for months that they are working on a plan to repeal and replace Obamacare in the Trump era. Now we have the outline of that plan, and it looks as if it would redirect federal support away from poorer Americans and toward people who are wealthier.

A white paper drafted by House leadership and the staff of the House and Senate committees that oversee health policy details a structure that could replace large sections of the Affordable Care Act. Crucially, the proposal largely contains provisions that could be passed through a special budget process that requires only 50 Senate votes, and fulfills President Trump’s promise that the repeal and replacement of the law would take place “simultaneously.”

The plan would make major changes in how health care is financed for Americans who don’t get coverage from work. It would greatly expand the number of Americans who could benefit from federal help in buying health insurance, but it would change who benefits most from that support.

Obamacare, as the A.C.A. is known, extended health coverage to 20 million Americans through two main mechanisms. It expanded Medicaid coverage to Americans below or just above the poverty line in states that participated, and it offered income-based tax credits for middle-income people to buy their own insurance. Obamacare was a redistributive law, transferring money from rich to poor.

well, and making it too expensive for many people now benefiting from it now to continue to purchase insurance.

humanoid.panda

I seriously doubt that as written, this can get through senate. It’s going to drastically reduce healthy people’s insurance rates, while obliging insurance companies to take on the sick..

Uneekness

Yeah, but this plan is supposed to be done as part of budget reconciliation, so as to avoid the filibuster. So why would it get hung up in the Senate?

Domino

There are Senate Republicans who are nervous about upsetting the system. Weird that the chamber that is supposed to be less responsive to the will of the people is, in fact, the one most in tune with it.

Linnaeus

They can’t be gerrymandered into safe seats.

Domino

True. But then again, 2 of the most vocal critics I’ve seen about the current Republicans plan are Alexander and Corker, both from Tennessee.

efgoldman

But then again, 2 of the most vocal critics I’ve seen about the current Republicans plan are Alexander and Corker, both from Tennessee.

There are apparently six or seven senate Republiklowns who will not go along with the Granny Starver, in spite of their idiot constituents.

Murc

They can’t be gerrymandered into safe seats.

Pedantry: this isn’t how modern gerrymandering works. You don’t want to gerrymander your own people into safe seats; that’s counter-productive.

What you want to do is gerrymander your opponents into safe seats, attempting to cram as many of their voters as possible into districts where they win by like 75% or greater of the vote.

Then you carve as many seats out as possible for yourselves that have about a 55-45 split. Those seats are mostly safe, and you can get a lot more of them than your opponents, which will usually result in a legislative majority, which is what you want and is a higher priority than guaranteeing any one individual seat is safe.

gmack

Yes, well put. It’s also why this kind of gerrymandering can be counterproductive in a wave election. If the Republicans are highly demoralized in 2018 and the Democrats are highly energized….

Mark Field

It looks like the plan is to undermine the ACA with changes which make it impossible to function properly, then try to blame the collapse on Obama’s poor design.

They can try that. I don’t think it will work. If they pass something–particularly if supporters of the ACA rally on its behalf and fight tooth and nail to defend it–there will be no way for them not to own the outcome of that bill.

I know pretty much everyone here already agrees with me, but I’ll just state it anyway. This is the hill we want to die on. It’s not just an important piece of legislation (lives literally are at stake), but if we can raise the cost of repeal high enough, we might torpedo the Republicans’ efforts. And that will produce consequences for their caucus that are, well, highly positive for us.

Scott Lemieux

100% correct. This is one case where the political and the substantive are aligned perfectly.

Mark Field

Agreed on the need for the fight(s). A bit less confident that the public at large will blame the Rs.

Lord Jesus Perm

So glad we got to keep neoliberalsome like Clinton and Neera Tanden away from the White House so Ryan could gut healthcare.

Lord Jesus Perm

Neoliberals*

Colin Day

Engage sarcasm detector.

jim, some guy in iowa

and for another group of tragically short-sighted people ACA repeal is an unintended consequence of their gun fetishes and wanting the boot put into all those weird, non-straightwhitechristians who think they have rights as citizens too

Mike in DC

Susan Sarandon is wondering why you’re bringing up old shit.

jayackroyd

Well I am certainly. Where’s the upside in beating this one anymore? What joy does it offer?

Dirtbag Neera! I had a couple of interaction with a high ranking EllisonOrBust person on Twitter, and I was honestly shocked to discover that when he talks about removing centrist elites, what he meant, specifically, was her and a couple other think tankers.

Scott Lemieux

But Tanden’s critics assure me that Trump will cut a great deal with Big Pharma! It will be yooooooge! We’re having the meatloaf!

humanoid.panda

Did you catch Jiliani’s persuasive argument that what the left needs to do is to gain influence in GOP. Strategy!

Scott Lemieux

LOL. Fucking politics, how does it work?

(((Malaclypse)))

A friend of mine recently decided that Warren was #nothissenator, because she didn’t persuade a single Republican to vote against DeVos.

humanoid.panda

Which is funny, because, you know, two republicans did vote against Devos..

efgoldman

two republicans did vote against Devos..

Yes, but Liz didn’t use her magic aura to MAKE them!

[I love Liz, even though I no longer live in MA, but some of these people are taking green lanternism to levels that exceed even Obama’s]

lunaticllama

She even got one in a culturally similar and nearly neighboring state to vote against Devos!

Scott Lemieux

Well, I am reliably told that Obama was a feckless incompetent because he placed too much faith in bipartisanship, and a feckless incompetent because he couldn’t get Olympia Snowe and Susan Collins to vote for a $5 trillion stimulus package, so it makes sense.

Rob in CT

What do you even do with that?

malraux

Yeah, I’ve run into the idea that warren is a sellout centrist because she didn’t come out hard for Bernie in the primary and is still in the Democratic Party. Anyone who raises the idea of warren 2020 is too neoliberal to be a serious thinker.

I…have some issues with that idea.

Scott Lemieux

I am also very reliably informed that the most progressive labor secretary since FDR is a enemy of labor because he backed Hillary Clinton for the Democratic nomination. I hope soon neolibrals like Warren and Perez will be purged from the party in favor of real left-wingers like Tulsi Gabbard.

malraux

Its striking how exact you got it, right down to the specific endorsement of Gabbard.

Redwood Rhiadra

This is why I think the Democratic Party is doomed for 2018 and 2020. The hard Left is clearly in the process of breaking away from the Democratic coalition (when they don’t get the purge of the “neoliberals” they are demanding, they will leave), and will probably form a relatively large third party (large for a 3rd party – maybe 15%) or substantially expand the Green Party.

And Trump will then win re-election 40/35/15.

nemdam

On a slightly more serious note, this is why I’m skeptical of the the talk about how Warren would crush it in a Dem primary and energize the left wing of the party. The second she becomes a real candidate and says nice things about the Democratic party and takes positions that aren’t the farthest left possible, her purity left fans will turn on her and call her a neoliberal sellout.

This is note to say Warren is a bad candidate or shouldn’t run or anything about Warren. She’s great. But I’m dubious, to put it mildly, that she is some special white knight that will solve all of the Democratic parties woes and usher into some left wing utopia.

malraux

Indeed, the problem with succeeding as an antiestablishment campaigner is that once you win you become the establishment.

efgoldman

The second she becomes a real candidate and says nice things about the Democratic party and takes positions that aren’t the farthest left possible, her purity left fans will turn on her

But that’s pretty much true of ANY viable Dem candidate vs the purity ponies.

nemdam

Just want to add I found out that Connor Kilpatrick has soured on Warren because she is too focused on regulatory matters and was a Republican until the ’90s. But Bernie is a mastermind beyond he joined a Trotskyist youth group.

Would this remain the same if there wasn’t someone like Bernie Sanders involved?

Strictly conjecture, but a lot of Sanders supporters (people new to politics, I’m thinking is a common thread) actually flat out refused to listen to anything Hillary Clinton had to say because she’s obviously a Republican and worse than Hitler.

nemdam

Also just discovered that H.A. Goodman thinks only Bernie, Nina Turner, and Tulsi Gabbard can win in 2020.

Tsam: they have turned on booker and warren based on some meaningless votes. I don’t know if the answer is to have them abandon every politician and realize it doesn’t work or just jump onto the newest politician.

tsam

I’ve been noticing from the HA! types lately (Hitlery Clinton is literally Satan types) this weird fascination with Tulsi Gabbard. I mean, she seems pretty damn good and smart, but we’re the only people who know her name and I don’t think she has a chance at a presidential run.

tsam

Tsam: they have turned on booker and warren based on some meaningless votes. I don’t know if the answer is to have them abandon every politician and realize it doesn’t work or just jump onto the newest politician.

Well, there’s one common thread, a profound misunderstanding of how politics work in the USA. It’s unfortunate because it’s another one of those ideologies (like term limits crankery) that attracts political noobs and damages their ability to participate in elections in an effective way.

Rob in CT

To be scrupulously fair, Booker has some actual issues and I doubt they turned on him because they never liked him in the first place (and may actually have for substantive reasons).

Warren… yeesh.

nemdam

They only like Tulsi Gabbard because she was an early and enthusiastic supporter of Bernie and even resigned from the dreaded DWS run DNC to do it. Her rhetoric also suggests she downplays identity politics.

efgoldman

Also just discovered that H.A. Goodman thinks only Bernie, Nina Turner, and Tulsi Gabbard can win in 2020.

Gakk. I first read this as Tina Turner…..

Lurking Canadian

Noam Chomsky was endorsing Clinton by Nov 8.

When you are standing somewhere that Noam Chomsky looks like a neoliberal sellout, it’s time to consider maybe the problem is you.

NoMoreAltCenter

Adolph Reed Jr. (who notably dunked on Obama in 1996 in an underrated gem) also endorsed Clinton. Just like Chomsky, he did so because Trump was too terrible to imagine.

Yet here we are.

gmack

Tsam: they have turned on booker and warren based on some meaningless votes.

Not to sound like a lefty purity pony, but this seems wrong. They dislike Booker because of his tendency to support “school choice” reforms and for his statements criticizing Obama’s attack on Bain Capital in the 2012 election campaign. The recent spate of attacks on Booker’s vote are all rooted in those criticisms. The vote might have been meaningless, but for his critics, it symbolized the problematic aspects of of his political position.

For the record, I share these criticisms of Booker. Obviously, I’d support him if he won the Democratic nomination, but his competition in the nomination campaign would have to be pretty bad for me to support him in the nomination process.

pseudalicious

Omg, that Conor Kilpatrick link. Bernie, in his youth, wrote “feminist” stuff about “sexuality” that would make liberals blush? You mean his essay he wrote when he was a dumb college kid* about men fantasizing about raping women and women fantasizing about being raped and it was basically, “Weird, right? Crazy!”

*now, I like Bernie, and again, he was a dumb college kid at the time. Which is the point. Simeone de fucking Beauvoir he was not.

malraux

No, booker moved into the sellout crowd based on his vote against bernies drug importation bill. The move against Bernie forced them to notice his school choice and closeness to Wall Street.

pseudalicious

But remember, there was NO sexism involved when BernieBros refused to vote for Hillary, because they said that if Warren was running, they’d TOTALLY vote for her! Unless she actually ran, then she’s totally a gross woman like teachers I hate and my dumb mom neoliberal shill.

Domino

What a shame he brings to his avatar.

Lord Jesus Perm

You know, I keep trying to come up with snarky things to say about Zaid, but all I can come up with is that he just isn’t that bright. Seriously, somebody read this shit:

One of the real weaknesses of the left is how little power it has in the GOP. Why don’t left people engage with it and win slots there?

And tell me somebody of reasonable intelligence wrote it. I fucking dare you.

Rob in CT

INT != WIS.

That’s the sort of thing I think only a fairly smart person could delude themselves into thinking…

tsam

That’ll solve all the problems. It’s all sunshine and fucking rainbows after cheap drugs, see?

jim, some guy in iowa

oh wow. Rainbows fucking would be the *definition* of psychedelic

Linnaeus

I may not hear “She’s a Rainbow” quite the same way again.

tsam

I LIKE WHERE THIS SUBTHREAD IS GOING

rea

I will give you caps of blue,
And silver sunlight for your hair;
All that soon will be,
Is what you mean to see, my love;

Won’t you try?
Won’t you try?

I do care that you do see!

It’s the time to leave my lady;
Yes it is, I know;
Round about and everywhere,
Sunshine instead of snow!

lunaticllama

I wonder if we’ll ever get another candidate of “acid, amnesty, and abortion” – even though McGovern was, umm, not a very successful nominee.

I also would be pretty happy if all the cool kids stopped messing around with molly and electronic dance music and brought back acid and psychedelia.

NoMoreAltCenter

Acid never went away if you aren’t a square

tsam

I also would be pretty happy if all the cool kids stopped messing around with molly and electronic dance music and brought back acid and psychedelia.

I’m down with making an earnest effort to bring it all back. Or at least just do a lot of acid.

nemdam

I shudder at the thought of arguing with an #EllisonOrBust person.

DAS

Obamacare was a redistributive law, transferring money from rich to poor.

The problem with the ACA is that it was also a redistributive law, transferring money from healthy to unhealthy people. And not all of those healthy people had a lot of extra money to transfer to unhealthy people. The ACA guidelines may have said a person could afford to spend over 9% of their income on health coverage, but how many people really could afford that kind of hit to their income, even if they earn 3x poverty wages?

Of course, Ryan’s plan no doubt will only make this worse. But since the redistribution from healthy people to unhealthy people (even if those healthy people are not all that wealthy) was baked into the ACA from the get-go, it’ll be easy for the GOP to blame the Democrats and for the media to report it as “both sides want poor healthy people to pay more for health care, so both sides”.

rea

The problem with the ACA is that it was also a redistributive law, transferring money from healthy to unhealthy people.

Not really, because in the long run, everyone will at some point need health care.

humanoid.panda

Also, the whole “media is going to report both sides” is slowly morphing into liberal version of MSM bias. The way media reports policy is simple: person X is getting hurt, and they are so photogenic! This hurt the Dems during the ACA era, and is going to hurt the GOP in the attempt-to-repeal ACA era.

[For a quick example: this morning, Yahoo News, the lowliest of low common denominator media sources, features a Charles Gaba chart about how many people will lose coverage in every congressional district on its main page. What bleeds, leads.]

Spider-Dan

On the one hand, you are likely correct about “both sides” and “MSM bias.”

On the other hand (i.e. both sides), screaming “MSM bias!” for a quarter-century has had palpable returns for the right; notably, the MSM now feels compelled to, um, present both sides as if any two positions on the spectrum are equally valid as long as they are opposed.

So at a certain level, if “both sides” becomes our “MSM bias” – and is effective in modifying the behavior of the MSM – then isn’t that a good thing?

NewishLawyer

Concurred but there were ways in which the ACA could hurt young and healthy people more and these young and healthy people might not have that much money because of student loans, freelancing or underemployment instead of an old-school job with benefits, etc.

I wonder how many people found themselves in the position of making too much money to get an insurance discount but the full premium price could still pinch finances.

Another issue is that when you are a freelancer, income can be a rain and poor thing. I got damned lucky last year with a long-term gig over the summer that provided a high hourly wage and a nearly unlimited overtime. But at other times my income was zero. But in the end my annual income became more than enough to price me out of a subsidy and I will probably owe money to the IRS in April because constant income updates to Healthy CA is a pain.

humanoid.panda

Me and the wife make around 100K a year together, and both of us are self employed at the moment. It’s not that I’m complaining, but college loans+trying to get early start on retirement savings+ saving for house+rent+insurance does build up.

GeorgeBurnsWasRight

Obviously, depending upon where you live, 100K goes a lot further or not that far.

Nevertheless, now think of how hard it is for the family with 50K, and then the family with 30K. I honestly don’t know how they manage.

Back in 1970 I quit a job making not that much, really, even adjusted for inflation, because I was saving 2/3 of my paycheck. Living costs were just a lot less. And I’d say my standard of living isn’t that much higher now.

When I was a kid most middle class families had a wife who didn’t work. Now the wife does work, and it looks to me like at best the average family is doing no better with a second income added in then my parent’s generation were without it.

To be clear, I’m not attacking you, just commenting on how difficult it is to make ends meet these days.

tsam

I think it’s fairly common for these kinds of programs to have a chasm between fully qualifying for sufficient aid and earning enough that someone somewhere decided was enough that you don’t need the aid. It can be a lack of adjustment for local cost of living, poorly actuated tables, politicians lowering the bar, or just plain bad law.

The point is that these things can easily be fixed with a Congress that takes an interest in preserving these programs and making them work for the people. That hasn’t been the case in seven years.

DAS

Oftentimes getting the level of aid correct becomes a political football. If a program doesn’t provide enough subsidies, the GOP will attack the program because “you are forcing people to pay for [X] but only the poorest of the poor get any subsidies to help them”. OTOH, if the subsidies are more generous, the GOP will find someone with granite counter-tops who is getting a subsidy and make a big deal out of the waste of subsidizing health care (or what have you) for a family that can afford a place to live with granite counter-tops.

As you point out, failure to adjust for local cost of living is often part of the problem. And your final point is important too — if Congress (and the GOoPs in it in particular) were actually interested in fixing problems and making programs work (even allowing for conservatives to have different standards for what it means for a problem to be fixed and for a program to work), they would spend less time trying to make political hay out of the problems in programs in more time actually fixing them!

Of course, ultimately, the blame is on we the voters who vote for Congresscritters who spend time making political hay out of problems and dismissing those who actually fix problems because “the Congresscritter only fixed the problem because it was politically convenient to do so … therefore I’m gonna vote for the Congresscritter who is making a big stink about the problem”.

tsam

Of course, ultimately, the blame is on we the voters who vote for Congresscritters who spend time making political hay out of problems and dismissing those who actually fix problems

Right–and I so wish I knew a way to de-stigmatize these things. It’s so bad that people who USE them think nobody else should get them. We’re just one giant bucket fulla crabs here in the USA.

NewishLawyer

I wonder if the US is also too big for cost of living allowances or changes because what would a cost of living allowance be for a well-paid freelancer who lives in NYC or SF or Boston? Probably pretty high.

GFW

Cost of living allowances would be seen as favoring urban (elites or inner-city, take your pick) over the real murkins of the heartland.

efgoldman

these things can easily be fixed with a Congress that takes an interest in preserving these programs and making them work for the people.

And when you find that congress in an alternate universe, you should let us all know.

tsam

Maybe someday. There was a Congress in 09 and 10 that made the ACA. Hope lives on.

efgoldman

Maybe someday.

As my grandmother used to say: “I should live so long. How about a nice gless tea?”

efgoldman

dupe

humanoid.panda

That’s kinda a red herring. Any plan, single payer most assuredly included, includes transfers from healthy to sick people.

MaxUtility

Isn’t that just kind of the definition of insurance? My payments are transfers to someone whose house is on fire?

StellaB

However, most people will never have a house fire, but everyone except the very “lucky” (aka “Poor Joe, he died so young”) will eventually get old and have medical problems. In effect, you can think of health insurance not as transfer payments to less heqlthy people, but as payments for future care.

NoMoreAltCenter

That is absolutely a feature, not a bug.

Peterr

Every tax law is redistributive. The debate is over where the funds come from and where the benefits accrue.

The GOP default is that the money comes from people like THEM and the benefits come to people like US.

The progressive default is that the money comes from people who have and the benefits come to people who need.

Given this choice, I’ll go with the latter every time.

Mellano

“But since the redistribution from healthy people to unhealthy people (even if those healthy people are not all that wealthy) was baked into the ACA from the get-go, it’ll be easy for the GOP to blame the Democrats and for the media to report it as ‘both sides want poor healthy people to pay more for health care, so both sides.'”

The media can fall for bothsidesdoit anytime they want to, but “the GOP wants poor healthy people to pay more for health care than under the ACA (while cutting taxes for rich people)” is a more natural description of what makes the Ryan sketch/plan news.

humanoid.panda

The Times headline about this yesterday was “Ryan plan transfers money from poor to rich.”

Linnaeus

Liberal media!

Mellano

In fairness, that was only their “explainer” article under the Upshot brand (linked in the OP). The main news article was classic anodyne Newspaper of Record policy reporting: “House G.O.P. Leaders Outline Plan to Replace Obama Health Care Act” (there, the first paragraph required readers to a little more work to understand that “leaning heavily on tax credits to finance individual insurance purchases and sharply reducing federal payments to the 31 states that have expanded Medicaid eligibility” means “Ryan will throw a lot poor people off Medicaid”).

At least the Upshot link was placed directly beneath the main story’s blurb when they were both published on the Times homepage yesterday.

proportionwheel

“The problem with the ACA is that it was also a redistributive law, transferring money from healthy to unhealthy people”

All health insurance does that.

(edited to add the quote)

Scott Lemieux

The problem with the ACA is that it was also a redistributive law, transferring money from healthy to unhealthy people.

The ACA would have been so much stronger, politically, if it made subsidies available to lower-upper-middle class people like that lady. Sigh…

tsam

Also, the first run at implementing sweeping, massive changes to a fucked up system HAS TO BE PERFECT FROM THE START OR IT’S A MASSIVE FAILURE.

humanoid.panda

Did I say that?

tsam

No. Did I say you said that? It was adding the point that most people are utterly clueless about how reform and laws work.

efgoldman

most people are utterly clueless about how reform and laws work.

Truth, truth, truth.
These are, after all, low information voters – not just about candidates.

liberalrob

And when the knives are out before the plan is even rolled out, having a smooth rollout is of critical importance. Instead, they rushed it, predictably botched it, and the naysayers promptly had a field day.

tsam

Yeah–that was fucking nuts. “We didn’t think THAT many people would try to use the website”

WHAT TEH FUCKING SHIT?

humanoid.panda

I’m still angry at that failure. When your calling card is “effective governance” you don’t just “yeah sure” the techological side of things.

Rob in CT

Yes, that was really bad and I was furious about it.

efgoldman

Instead, they rushed it, predictably botched it, and the naysayers promptly had a field day.

And some of the participating states (hello, RI) weren’t ready, either.

j_doc

The national website was meant to be a backstop for a handful of low-population states for whom a state website wouldn’t make sense. They weren’t expecting so many highly populous states to refuse to create an exchange out of spite, any more than they expected so many states to refuse the Medicaid expansion out of spite.

Yeah, there was time in between the refusals and the rollout to adjust, but we’re talking an order of magnitude difference in the population served.

The lack of a law did precisely the same thing, except that the uninsured both waited to long to seek treatment and avoided preventative care entirely, and then went to emergency (astronomically priced) rooms for care.

You didn’t think that those of us who rarely use our $700/month health insurance plans weren’t paying to cover those costs, did you?

Hogan

And auto insurance just transfers money from people who don’t have accidents to people who have accidents. So unfair!

Scott Lemieux

I am outraged that my fire insurance premiums are distributing my income to people whose houses burned down!

tsam

I think we should have our income painted on our cars–that way those of us who pay higher taxes can always have the right of way on all the roads. Fair is fair, right?

rea

Ah, the Mercer Island plan.

BigHank53

If I recall correctly, one of the bike lanes that passes across the lake parallels a couple of the Mercer Island ramps. It’d be a couple seconds of work to toss a handful of roofing nails across the fence while you’re riding to work…

Rob in CT

Sadly, people do think like this.

FMguru

Strong overlap between those people and people who don’t understand how marginal tax rates work (“I turned down a raise because it would have put me in a higher tax bracket and end up costing me money”).

efgoldman

Strong overlap between those people and people who don’t understand how marginal tax rates work

I used to suck up all the OT I could get, while some of my colleagues would refuse it because “they took it all in taxes anyway.”
Supposedly educated people.

tsam

Whoa–I’d like to hire these people to work for me!

efgoldman

I’d like to hire these people to work for me!

The stupider thing is: some important bennies, notably matching 401k contributions, were based on total compensation.
What the fuck us wrong with people.

tsam

What the fuck us wrong with people.

Well, they hear something like that don’t bother to find out if it’s true or not. “My foreman says overtime takes all your money in taxes and he’s the foreman, see?” “HR says a pay increase will bump me up into the next tax bracket–NICE TRY, COMPANY!”

Rob in CT

Yes! I’ve ranted about this before, re: my mom.

liberalrob

I am outraged that my fire insurance premiums are distributing my income to people whose houses burned down!

Especially that neighbor I don’t like!

lunaticllama

Next thing you know, they’ll have us paying for the firemen that go to their house when they leave the stove on!

Dr. Ronnie James, DO

Why should my insurance premiums help pay for that woman over there who’s having a baby? I’m not a woman!

Scott Lemieux

In the piece I link to above, that was literally Lori Gottleib’s argument — “I already had a kid, why should I have to pay for maternity coverage now?”

Rob in CT

As others have pointed out, insurance by its nature involves taking luckier people’s money to pay for unluckier people’s claims. With health, this tends to break down to young/old, though not always.

However, yes, the ACA takes it up a notch by capping how much more the insurance companies can charge old people. This means younger/healtier pay more than they otherwise would, subsidizing the older/sicker.

I think the justification is sound – we’re all gonna get old (hopefully, anyway), and I’m not sure how to design a workable (key word, there) health insurance reform that doesn’t do this on some level (it’s certainly baked into the cake of “single payer”).

humanoid.panda

The best way of doing it, in a perfect world, really is some version of single payer. Israel, for instance, has a 5% payroll health tax, which funds a robust public insurance system- and people can buy supplementary insurance for extra services/ top doctors/age specific things. It’s not perfect,but its far less onerous on young people than the ACA.

In America ,seems really only solution is to throw money at the problem.

Rob in CT

Oh, I agree.

liberalrob

Just don't throw *my* money at it!

In a perfect world, everyone is responsible for their own health care and if they can't afford it, it's not my problem. I know they don't care if I get sick, so why should I care if they get sick?

Thus, we can’t have nice things. Like single-payer.

Redwood Rhiadra

Doing that in the US would require three times that (12-15% payroll tax).

(Approximately 20% of all healthcare in the US is paid for by Medicare. So paying for 100% of healthcare would cost ~5 times as much – maybe only 4 times because single payer is more efficient. Current Medicare payroll tax is 3%, so a single payer payroll tax would have to be 12-15%.)

NewishLawyer

I agree but what seems to be happening is that a lot or enough young people are deciding that the premiums of insurance are more expensive than the penalty fine unless you get some horrible catastrophic plan with a high deductible.

Rob in CT

Yes, the fine isn’t high enough/coverage isn’t cheap enough problem.

Domino

Hell, healthcare expenditure tends to abide by the Pareto Principle. So we’re really paying in case we fall into the 20% that consumes the vast amount of expenses. Vox had an article by Sarah Kliff the other day about a boy who spent the first 5 months of his life in ICU and who’s hospital bill ended up being just north of $2 million.

What is the counter to this? That we should let him die when his parents can no longer afford his care? These are the questions Republicans need to be forced to answer.

NewishLawyer

The GOP knows that it has no answer to this and very few except Interneters would say that the kid should die.

so-in-so

Not just internet trolls; recall the 2008 primary and the resounding cries of “let him die” about someone with no insurance.

tsam

Yeah, Ron Paul with his little shrug–“there’s nothing more we can do. Let him die”

Hogan

We’ve tried nothing, and we’re all out of ideas.

j_doc

The Pareto principle was also the source of much of the market dysfunction, since it was far more profitable for an insurer to figure out how to not cover those 20% or at least not pay their bills, than to, say, improve health care efficiency or keep the other 80% healthier.

The problem with the ACA is that it was also a redistributive law, transferring money from healthy to unhealthy people.

Yes. That’s how insurance works. If your house burns down, your insurance pays, but you never paid premiums to the value of the house – they’re paying you with other policyholders’ money.

Crusty

“But since the redistribution from healthy people to unhealthy people (even if those healthy people are not all that wealthy) was baked into the ACA from the get-go, it’ll be easy for the GOP to blame the Democrats and for the media to report it as “both sides want poor healthy people to pay more for health care, so both sides”.”

Um, isn’t the concept of health insurance itself based on redistribution from healthy people to unhealthy people? Which is fine. That’s how insurance works.

Healthcare is expensive. There are going to be times when people, rich or poor need procedures that they can’t pay for out of pocket. That’s what insurance is for. It works if everyone gets in the pool.

The USA spends over 9% of GDP on health care. So people in the middle of the income distribution and no employer subsidy should expect to spend about that as a baseline. This complaint is just reality tripping up the free ponies.

RonC

Can’t the ACA be both a dessert topping and a floor polish, in that it redistributes money and is a neoliberal framework to a degree? And by the way why does neoliberal always come up as being misspelled?

humanoid.panda

I think the problem is that that there are just too many meanings to the term neoliberalism. To the extent that if people were writing the ACA in the 1950s would probably have not gone with the exchanges/subsidies model, it does have some neoliberal undertones. On the other hand, if neoliberalism implies moving state functions of the state to the marketplace, hell no.

Redwood Rhiadra

“Neoliberal” today is just leftist code for “not sufficiently Communist.”

humanoid.panda

I think the problem is that that there are just too many meanings to the term neoliberalism. To the extent that if people were writing the ACA in the 1950s would probably have not gone with the exchanges/subsidies model, it does have some neoliberal undertones. On the other hand, if neoliberalism implies moving state functions to the marketplace, hell no.

jim, some guy in iowa

define “neoliberal”- is it when the government intervenes in what had been a private market? or is it when the government turns over a public service to private for-profit interests? or is *any* public/private partnership “neoliberal”?

humanoid.panda

It really depends on what you mean by term neoliberal.

If you mean, “policy informed by a general sense that subsidies and “nudges” within a market framework can be efficient public policy tools” yes, the ACA has neoliberal aspects.

If you mean “a monstrosity aimed to drain the bone marrow of the working class so that scumbag Neera may drink it” probably not.

Scott Lemieux

If “neoliberal” applies to a program that makes policy outcomes much more egalitarian while substantially raising taxes on the rich and increasing public expenditure and regulation bigly, what does it mean at that point, exactly?

humanoid.panda

Here I think where the disagreement lies: the people who wrote the ACA really did think things like competition and high deductibles are good policy, in the sense that they generate market signals that will help keep costs down. Sure, the imperfections of the ACA were 80% an outcome of political constratints. But the other 20% matter, too.

Domino

As Atrios points out, people really hate having to sing up for insurance. It’s not a pleasant experience, you can easily overlook something that comes back to bite you, and it takes forever if you actually need to contact someone at an insurance company.

Forcing people onto the exchanges may, in the medium and long run be the best plan, but Dems should’ve anticipated the frustration from this. Granted, I’m not sure how much good it would have done, but at least we’d have something.

rea

people really hate having to sing up for insurance.

Understandably. They rejected me because I was off-key.

liberalrob

Forcing people onto the exchanges may, in the medium and long run be the best plan

It was never the best plan and never will be. But it was the best plan that could pass Congress at the time.

The fundamental issue is considering health care as a for-profit service best provided by the private sector. Until we as a nation figure out that that concept is inherently flawed, if not outright evil, we will continually struggle to fit the square peg of profit into the round hole of health.

Rob in CT

Agreed, it’s not the best plan. The best plan is national health insurance.

We really are badly hamstrung by decisions made ~70 years ago. We’re way down this fucked up path of employer-provided (because tax advantaged) health insurance for most working-age people, single-payer for retirees and the very poor, and a giant shit sandwich for anyone else. That and mythology about self-reliance, socialism, etc.

gmack

I agree, broadly speaking. As humanoid.panda points out, there are people who really think that privatization and “market-based solutions” to stuff are the best solutions. They are, properly speaking, “neoliberals” in the sense that they have a particular ideological orientation toward public policy, freedom, and so on. This ideology, however, isn’t why we adopted the ACA. The Congress adopted the ACA because it was the best option they could get passed, given the current state of the coalition and the organization of power. The choice wasn’t between a “market-based solution to health care” (which isn’t, as Scott rightly points out, an apt description of the ACA in any case; see the Medicaid expansion) and a single payer system. The choice was between trying to provide better health coverage for as many people as we can and doing nothing.

Dr. Ronnie James, DO

So (and I think you may already know this), one of these “leftist vs. liberal” trolls spelled it out: “liberals” policies fix the failures of capitalism, and thus keep it alive; without “liberals,” the whole thing would come crashing down, ergo “liberals” are the real enemy. From this vantage point, “neoliberals” are just, like, lame-o liberals who are alive today (as opposed to, say, Woodie Guthrie). sorry if you already knew this – I had no inkling.

I asked how this paradigm was relevant to my patients who will soon be unable to afford insulin & blood pressure medication, but the reply was just a bunch of punctuation marks and cursing.

NoMoreAltCenter

The hope, of course, is that the ACA can survive the Great Orange One and eventually evolve into something like Medicare for All. But denying that the ACA is neoliberal is like denying that water is wet. It is good, but absolutely not good enough.

Any Dem that wants to shield the ACA from criticism on the grounds of protecting Obama’s ego needs to be horsewhipped.

Rob in CT

Any Dem that wants to shield the ACA from criticism on the grounds of protecting Obama’s ego

Well that’s not a strawman at ALL.

Dude, I think you have near 100% agreement amongst the Hive Mind ™ that the ACA is good but not good enough and we’d prefer more. Some minor disagreement might erupt over choosing between something like ACA + public option with better subsidization vs. full on single payer, but if you take “what could we actually pass in real life” out of the equation I think we’re back to near 100% agreement on single payer.

I believe this includes Obama of the giant ego, by the way, not that it matters.

NoMoreAltCenter

“Well that’s not a strawman at ALL.”

I am not in a primary refighting mood today, but yeah, people absolutely were asserting during that period that the ACA was a signature accomplishment of Obama and pushing for single payer was embarrassing to him.

Rob in CT

Embarrassing to Obama, or of dubious political value given that the alternative to the ACA at this moment is not single payer but whatever awfulness the GOP is going to cook up?

During the primaries, we (LGM commentariat/Hive Mind) extensively debated Bernie’s push for SP here and lots of us were fine with it but also were a little worried that slagging the ACA from the left* just added to the noise telling people the ACA sucks (so why care about keeping it?). I was hoping we could thread that needle – making the argument, as you have, that the ACA is good but not good enough.

I don’t think we threaded that needle.

* to be clear, I don’t know think Bernie slagged it. A fair number of Bernie supporters absolutely did, though, and I think that was unhelpful.

NoMoreAltCenter

It frankly left an impression on me when I volunteered with Obama 2012 how many people I called who said they were fed up with Obama because of how underwhelming the ACA was. And then selling the ACA as an insurance agent to countless irate middle classers whose premiums more than doubled…

We need to keep single payer at the forefront. Any Dem party that abandons it isn’t one I want anything to do with.

Rob in CT

Pushing for “protect and improve the ACA” isn’t giving up on single-payer.

Whether by adding a public option, a medicare buy-in for 55+, or both, we could (with a Dem congress) move towards SP under the ACA framework.

That may be dead now, and so now I have zero qualms about just pushing for SP. AT THE TIME, running as the incumbent party defending a good-but-not-perfect improvement, slagging it in favor of the policy of our dreams was, IMO, a dangerous play. My personal take was: full-throated defense of the ACA as an improvement on the status quo ante, while agreeing that SP was superior if the person you were talking to brought it up.

Chetsky

then selling the ACA as an insurance agent to countless irate middle classers whose premiums more than doubled…

I keep on hearing these anecdotes, but (a) every time I read somebody like Mayhew or Drum, they claim (sometimes backed up with something that looks like data) that it ain’t so, and (b) my own experience on the exchange (with zero subsidy, lemme tellya) is that, no, my premium went up (for 2016) by 10% or so, sure, not happy, but no cause for rending of garments, ffs.

I remember reading about that woman who regretted Trump-ing, but had done it b/c her insurance premium was bigger than her mortgage? Really? I mean, again, I have zero subsidy, have a nice silver plan, and I know the gold-plated plans aren’t THAT much more expensive . And heck, I’m 52. Not exactly a spring chicken.

I keep on wondering: where are these people who are paying literally thru the nose for their insurance?

[to be clear: I pay 700/mo. used to be 600/mo. In CA. Not peanuts. But not that different from the COBRA from my last employer, either.]

So: can you show your homework on this?

tsam

But denying that the ACA is neoliberal is like denying that water is wet. It is good, but absolutely not good enough.

Well this certainly is important. We’ll be sure to keep this in mind. Also, I had no idea that this was a compromise between nothing and something that actually accomplishes affordable health care for anyone. Thanks for letting us in on that little secret.

NoMoreAltCenter

Yw

efgoldman

But denying that the ACA is neoliberal is like denying that water is wet.

Oh just shove it up your ass. No-one knows or cares what neoliberal even means. In this context it’s meaningless. Just another buzz word.

Any Dem that wants to shield the ACA from criticism on the grounds of protecting Obama’s ego needs to be horsewhipped.

Who, with actual influence, has said that. Some blog commenters?

Fucking troll.

NoMoreAltCenter

That is a mean thing to say.

Scott Lemieux

But denying that the ACA is neoliberal is like denying that water is wet. It is good, but absolutely not good enough.

To state the obvious, the fact that the ACA is suboptimal in absolute terms does not make it neoliberal.

Any Dem that wants to shield the ACA from criticism on the grounds of protecting Obama’s ego needs to be horsewhipped.

I don’t see the point in horsewhipping imaginary people, but your fantasies are your own.

Heaven help the poor soul who has to type up Brooks’ crayon scribbled drafts.

NewishLawyer

LeeEsq has pointed this out before (and other disagreed with him) but there is some evidence that the European right made its peace with the idea of a welfare state and some variant of single-payer, universal healthcare. They also made their peace more with various social changes in the 1960s.

The reasons for doing so are varied perhaps. There is a more of a tradition of Commonwealth and Noblese Oblige. European aristocrats never really had the holly-roller in them. Even in Protestant England, the Anglican Church was supposed to be more easy going than the dissenting churches and the Catholics.

In the US, the American right has always resisted the welfare state even in its smallest components. Social Security and Medicaid might be third rails but there are still those who say the programs are doomed to collapse and are generally immoral and need to be chucked.

Libertarianism is also much more of an American thing. I can count the number of non-American Libertarians I know of on one hand. This doesn’t seem to end. Every generation seems to have kids who discover Ayn Rand, Robert Nozick, Hayeck, and Milton Freidman and think such writers are the best things ever. Every generation of Americans produces a new batch of ultra-libertarians prone to weird thought experiments like Bryan Caplan claiming mental illness does not exist and is merely a personal choice.*

I have no idea what can be done to combat this along with the fact that our right-wingers think Griswold can be overturned and we can become a repressive society again.

*My theory is that right-wing libertarian economists are prone to calling mental illness not real because mental illness requires acknowledging some adults cannot fend for themselves and need state help.

humanoid.panda

LeeEsq has pointed this out before (and other disagreed with him) but there is some evidence that the European right made its peace with the idea of a welfare state and some variant of single-payer, universal healthcare. They also made their peace more with various social changes in the 1960s.

One thing that terrifies me is that if French runoff is Fillon against Le-Pen, she will run hard to the left, as defender of welfare state and secularism. And if she pulls that off, God helps us all..

NewishLawyer

This has been a right-wing populist play in Europe for a while though, right? “We are the true defenders of European secularlism and the immigrants will not be allowed to disrupt this.”

France is hard to place in the American context in that they have always accepted more regulation. Americans would bristle at laws mandating “Product can only call itself product if it comes from this region and is produced in this way.” But they are also fairly conservative by European standards and even if secular, they have warm fuzzies for the Catholic Church.

LeeEsq

Granted two of them are Jewish and all of them are young but none of the French people I know have warm fuzzies for the Catholic Church. I know several French people.

Chetsky

yeah, we only do for the case of “product can only call it self product if it’s made by company X”.

guthrie

“The european right” made it’s peace with more welfare state stuff starting with Bismark basically trying to buy the workers with offers of pensions and suchlike, with the aim of making them less radical and socialist.

Noted landmarks since then have included British rulers realising after the Boer war that there’s no use having mass conscription if your city dwelling plebeian is too badly nourished to be able to fight effectively, so they started supporting school meals and suchlike.
The thing you’ve not really said is that we’ve got a long history of authority in charge of things, and therefore the authority wants to run things their way, which includes having lots of healthy people to defend the authority and their power.
Think more centralised, less deliberately anarchic than the USA.
Which oddly enough was founded by rebellious rich folk who wanted to be in charge of themselves. But somehow don’t identify enough with the entire country to actually feed it properly. Whereas in Europe they did.

LeeEsq

You also have a society more accepting of state paternalism. Several years ago, there were a spat of books about French dieting because they are statistically slender even though French food is very rich. Slate had an article that the French tend to be more slender than their Anglophone countries despite a heavy calories cuisine because the Third Republic managed to enforce eating habits like no snacking during the late 19th and early 20th century. Anglophone countries are generally less accepting of state paternalism.

Most European states were founded with the help of the church and the churches have made their peace with the modern state. There are elements in recent decades that deplore the low rates of religious participation, but these are not mostly anti-state elements. The change may have to do with the loss of Communism as a presumed secular support for atheism. This allows the religious right to ally with the state in the care of subjects in a way that does not happen in the US except in the case of the more liberal denominations (which are identified with the WASP ruling class, largely, the Society of Friends being an example). The conservative denominations largely oppose secular state power.

This may be less true in England, though, where social welfare was divorced from religion and assigned to the state, centuries ago. Our policies follow the UK’s more than, say, France’s.

LeeEsq

There are also differences between where the ruling classes originates. The European ruling classes come from the landed nobility and some of them took their paternal duties seriously or at least wanted to look like it. The American upper classes where always independent business men and professionals with no official social responsibilities like the landed nobility would have.

1b. It’s kind of an exaggeration anyway. The idea that only someone “born to rule”, much less that the European aristocracy really cared about ruling, could have a responsible mindset, kind of takes the (mostly latter-day, fantasizing) apolologists for reaction at face value.

2. This is kind of the Marxist perspective and it’s not, let’s say, exactly 100% accurate.

IOW on second or third thought it’s kind of all bs.

LeeEsq

Southern plantations owners loved to play gentry and the country gentleman but any close examination reveals that they were business men at heart and some of them were very skilled at business.

Totally off topic, too, but my town is in the process of considering switching to a city charter. I was reminded of this by a tempted tangent on the subject of the New England Town Meeting, at which every adult voter is permitted to attend, speak, and vote. My town has about 75,000 residents and a “representative town meeting” where each of 18 precincts has in theory 12 reps. The proposed charter would have something like 5 council districts, with two at-large council members and a mayor (all salaried, I believe). Earlier today I saw a flyer against the charter, arguing that with more reps under the current system there will be more minority representation. Well, under our current system, well over half the meeting is from the more affluent sections of town, because only about three precincts have a full slate of reps and at least two have no representation at all. (Several precincts consist of three married couples or parents and children living at the same address; one consists of three addresses all on the same street, for a total of six members.) It seems obvious to me that having one vote out of seven and influence over two more council seats, plus the mayor, is superior to having three representatives out of two hundred, but maybe I’m missing something.

LeeEsq

They could go for an elected City Council with a larger size than seven. I think a city of your size in a European country would have a few dozen council members.

lunaticllama

In several European countries, the church and state are much more intertwined institutions. For example, Denmark has an official state church, but is very secular and has a very low rate of churchgoing. None the less, the Danes generally support the state keeping the church going, mostly for reasons of tradition and/or nostalgia (i.e., crowning their monarchs who have no real power.)

nemdam

This is admittedly probably a sloppy take. But it’s always my impression that European politics are just generally more chaotic compared to the relatively stable US. Europe is always having more wars, revolutions, uprisings, and people getting conquered by foreigners which creates a culture for more radical politics. Best way to keep radicalism in check is to pay people off.

It just seems the European aristocrats have internalized the fact that if you don’t actually serve the people, they get restless, and it’s in their best interest in the long term to keep the people in check.

Chetsky

My understanding is, the welfare state worked in Europe partly b/c they lacked the heaving dusky-hued masses, taking what they didn’t earn and lamming it in their Cadillacs with trunks full of king crab legs and t-bones. Or something.

And ISTR at least a couple of times reading that that consensus is starting to fall apart. E.g. in Scandinavia, where Romany homeless beggars are being roundly demonized and in some cases attacked. At least, the Nordics are decent enough to go upbrad the Romanians for treating their Rumany (not a mis-spelling, apparently the Romany in question often hail from Romania, I think) for their mistreatment of their indigenous Romany populations.

Anyway, all I’m sayin’ is, the social consensus seems to depend a lot on everybody lookin’ alike.

humanoid.panda

Off topic: Trump breaks new ground, bigly. He is now at 38% approval at Gallup – equivalent to Obama’s lowest grade, ever. Truly, he is accomplishing something no president accomplish ever, libtards.

Also, at net approval of -18, he is now where W was in September 2006.

nemdam

Who else is bored of winning?

lunaticllama

He did so much, so fast within the first month that he's basically already on his second term.

Gone2Ground

Medicaid is also the mechanism by which many, many elderly people pay for their skilled nursing care (in nursing homes), after they’ve spent every. Last. Dime. on health care previously. (And no, you can’t just give your money or your home away to your kids. They check, and I think the timeframe is 5 years back. Insurance for long term care is also very expensive and costs almost as much as just paying to live in a nursing home.

Medicare does NOT cover skilled nursing – it covers 21 days of rehab.) There are lots of cool provisions in the ACA for paying for people to get help in-home, which I’m sure our overlords have in their crosshairs, but the fact is that advanced or even mid-level dementia, Alzheimer’s, or any other of myriad elderly health problems mean lots of folks end up in skilled nursing.

Given how many Boomers are going to need this benefit in the future, I don’t see this getting very far, although I don’t see any details in this “Plan” about this issue. Skilled nursing costs upwards of $4000 per month. In some parts of the country, perhaps half as much. It ain’t cheap, and even then, show of hands on who wants to live out their days in even a nice nursing home?

liberalrob

What’s the alternative? How can I calculate the opportunity cost if I don’t know the alternatives?

The problem basically is that the Republicans are too stupid to understand, as the Democrats do instinctually, that minor concessions like the ACA help capitalist domination flourish in the long run. The carrot is less costly than the stick 90 percent of the time.

The Republicans have forgotten the lessons that the Master Class learned in the Interwar Period because they are morons.

Hogan

Almost all political conflict, especially in the US, boils down to a fight between the Sane Billionaires and the Insane Billionaires. It generally follows this template:

INSANE BILLIONAIRES: Let’s kill everyone and take their money!

SANE BILLIONAIRES: I like the way you think. I really do. But if we keep everyone alive, and working for us, we’ll make even more money, in the long term.

INSANE BILLIONAIRES: You communist!!!

So from a progressive perspective, you always have to hope the Sane Billionaires win. Still, there’s generally a huge chasm between what the Sane Billionaires want and what progressives want.

Rob in CT

I’ve always liked that, but then I’m a sane progressive. There are those who look at that last line and decide there’s not a dime’s worth of difference so bring on the insane billionaires so the revolution will come. Too bad the revolution has at least a 50% chance of being a fascist one.

tsam

but then I’m a sane progressive.

Come to the dark side, Rob. We got cookies.

Rob in CT

No ponies? Sod off.

tsam

(GASP) RUDE!

j_doc

So this is a warmed-over version of Price’s plan to replace the income-based subsidies with age-based subsidies. If that were the only substantive change, maybe. In general, entitlements work better, have lower overhead, encourage social mobility more, and are more popular if you remove any income screening from the benefit side. Make them progressive on the tax side and universal on the benefit side.

But the magic asterisks will make this insane. The subsidies will be fixed, unrelated to the actual cost of insurance, and therefore useless for most people. The age stratification won’t keep pace with the dramatic increase in insurance cost with age. Most impactfully, the Medicaid expansion will be phased out, and original Medicaid block-granted and shrunken. This is awful, terrible policy on every level. And it only meets the “don’t throw people out of coverage” criteria in the sense of “we’ll gradually phase in throwing people out of coverage”.

Part of me wants to say that the only part of the ACA they really care about is the high-income tax surcharge, so why don’t they just axe that and call it a repeal? Far less harm done than any alternative.

bs

Because, for today’s Republicans, the deaths of poor people (including me) are an objective good in themselves, just like those tax cuts for the rich. Plus, the guy who signed the ACA had the temerity to be both a Democrat and black, so nothing he did must stand.